Health Care Stagnation

In December, the Los Angeles Times reported — very briefly — that from 2007 to 2008, life expectancy in the United States declined by 0.1 year. It should have been the lead story of every newspaper in the country with the largest possible headlines (“LESS LIFE“). Did 9/11 reduce life expectancy this much? Of course not. Did World War II? Not in a visible way — American life expectancy rose during World War II. I can’t think any event in the last 100 years that made such a difference to Americans. The decline is even more newsworthy when you realize: 1. It is the continuation of trends. The yearly increase in life expectancy has been dropping for about the last 40 years. 2. Americans spend far more on health care than any other country. Meaning vast resources have been available to translate new discoveries into practice. 3. Americans spend far more on health research than any other country and should be the first to benefit from new discoveries.

Maybe I’m biased (because my research is health-related) but I think this is the biggest event of our time. It is the Industrial Revolution in reverse — progress grinding to a halt. For no obvious reason, just as the Industrial Revolution had no obvious reason. Health researchers have been given billions of dollars to improve our health, the whole system has been given tens of billions of dollars, and the result is … nothing. Worse than nothing.

No journalist, with the exception of Gary Taubes, seems the least bit aware of this. It is a difficult story to cover, true. But several journalists, such as health writers for The New Yorker (Atul Gawande, Michael Specter, and Jerome Groopman) are perfectly capable of covering it. They haven’t. With a few exceptions, they write about progress (e.g., Peter Provonost’s checklists). It is like only reporting instances when Dirk Nowitzki missed a free throw. Each instance is true but the big picture they create — he misses all free throws — is profoundly false.

Among academics, the stagnation has received a tiny amount of attention. In a recent paper (gated), two University of Southern California professors, considering a wider time period, point out that there has been some improvement in how long you live after you get sick, but no improvement in how long you live before getting sick. Here is how the discussion section of their article begins:

There is substantial evidence that we have done little to date [meaning: from the 1960s to the 1990s] to eliminate or delay disease or the physiological changes that are linked to age. For example, the incidence of a first heart attack has remained relatively stable between the 1960s and 1990s and the incidence of some of the most important cancers has been increasing until very recently. Similarly, there have been substantial increases in the incidence of diabetes in the last decades.

Here is my explanation of the paradox of: 1. Enormous and increasing health care costs. 2. Vast amounts spent on research. 3. No better health. Health researchers, such as medical school professors, shape their research to favor expensive treatments, such as expensive drugs. In fact, the best treatments would cost nothing (e.g., the Shangri-La Diet). To make the expensive treatments seem worth studying, they invent utterly false theories and claim to believe them. For an example (research about depression), see The Emperor’s New Drugs by Irving Kirsch. Because health researchers are forced to worship absurd theories, they are incapable of good research. Absence of good research is why there is no progress. The health care supply chain — everyone between you and the research, such as doctors, nurses, drug company employees, hospital employees, alternative medicine practitioners, medical device makers, and so on — is happy with the situation (useless research) because it ensures that little will change and they will continue to get paid. They are the supposed experts — and remain silent.

It is human nature that everyone in the supply chain remains silent. They are protecting their jobs. But the silence of the journalists is The Emperor’s New Clothes writ large. To explain why smart journalists fail to notice the stagnation, I think you have to go back to studies of conformity. When everyone you talk to — people in the supply chain — says black = white (i.e., that progress is being made), you say the same thing.

44 Replies to “Health Care Stagnation”

I think this is possibly the best and most important post you have ever written. A decline in life expectancy in the U.S. is absolutely shameful. I hope the journalists you mentioned sit up and take notice. Lack of integrity in the U.S. health, economic and political systems is a major problem and is causing us to stagnate. Corruption and poverty go hand in hand. Without independent journalists and bloggers shining a very bright light on such conflicts of interest, they will continue to go on unaddressed. Maybe this post will get the ball rolling.

You didn’t mention the huge breakthrough in health care-the internet. It allows us to use personal science to give us a disease free life. From my reading of research papers, advances are being made in biochemistry but it is not reaching the medical profession. I am using those advances to bypass the doctors.

Life expectancy as a measure of the quality of a health care system has its limitations. For example, here in the United States, we often get criticized because our life expectancy isn’t the highest despite having the highest health care costs, but if you make a simple adjustment for life expectancy by excluding fatal injuries, then suddenly we have the highest life expectancy. Why? Maybe it’s because of a greater degree of deaths from car accidents since car ownership is so high in the U.S. Maybe it is because of a high degree of violent deaths. I’m not certain, but it is highly likely to be a demographic issue rather than a issue of not responding effectively to fatal injuries.

The United States also faces the challenge of soaring obesity rates (and people who are just overweight and not classified as obese), which is another factor that is a demographic issue and doesn’t reflect poorly on the health care system. The obesity rate in the US is far higher than most other nations of the world. The fact that it has been steadily getting worse could be contributing to a stagnating life expectancy.

It would probably be preferable to track more precise measures of health care quality. One example might be historical 5-year cancer survival rates. The incidence of cancer in a country is probably fairly closely related to demographics, whereas the survival of cancer is probably somewhat less so.

I agree that personal science could go a long way to reducing costs and improving outcomes. I think far too often patients are put on drugs (such as statins) without really tracking the results in any careful way. For example, my mother is on medication for high blood pressure. It would be interesting to track her results without the medication for a month, then with it, and then without it again. This would probably be sacrilegious to both the medical community and my mother though. It’s a shame.

Mark,
maybe I misunderstood your second paragraph about obesity being a demographic issue… surely it is, but I tend to view it as a result of the failure of the health care system, not just a standalone factor outside it which contributes to the decrease of life expectancy.

Mark, like Tomas I see obesity as a failure of the health care system. Among other health problems, obesity makes diabetes more likely.

“Should we blame doctors and nurses for obesity?” Well, yes, to some extent. Doctors and nurses seem to be satisfied with weight-loss advice that obviously doesn’t work. (A typical doctor says “eat less, move more.”) If doctors and nurses are brain-dead, as in this case they appear to be, that’s a real problem. Either they should shut up (“sorry, Mr. Jones, your weight is an enormous health problem but I have no idea what to do about it”) or say something sensible.

Don’t get me wrong. There is definitely room for improvement in the health care community’s response to obesity. Their understanding of nutrition and exercise is in serious need of updating, but the real challenge is in teaching others how to change their behavior in a sustainable way. I personally don’t blame the medical community for not having solved this immensely difficult problem, especially when the medical community has essentially zero control over the behaviors of their patients.

if i were to guess why, probably just that a higher percentage of children are born into poverty each year and poor people don’t live as long. so not health care per se but income distribution. or it could be a statistical artifact of same.

In Britain we are told that continuous increases in our life expectancy is one of the main reasons that our pension schemes are in financial trouble.
As far as I know this is true. Is the decline unique to the USA?

Seth, I recommend you Google Bruce Charlton’s blog, as well as his “The story of real science”, for the very best discussion I’ve seen of stagnation in both medicine and science in general. The man sees reality on a higher level than most people can.

2. Incidence of cancer in the United State (and probably in other developed nations) is likely increasing due to changing lifestyle and increasing exposure to risk factors (e.g. chemical products, tanning).

3. It’s extremely unlikely that healthcare researchers are deliberately slowing down the progress of medical research to a halt in order to retain their jobs. Are we really worried that making people’s lives better will cause reduced funding in health research because we no longer need improvements in healthcare? – only in your wildest dreams. There may be problems with how funding agencies tend to fund the research topics that are “hot” right now and a lot of researchers jump on the bandwagon when they really don’t have any innovative ideas. However, I think it’s unfathomable that people are intentionally studying problems that have no prospects of improving the quality of life, given that a healthcare researcher’s success mostly dependens on how much of a positive impact one’s research program has on healthcare (duh!).

E. coli (is that your real name?), you write “I think it’s unfathomable that people are intentionally studying problems that have no prospects of improving the quality of life, given that a healthcare researcher’s success mostly depends on how much of a positive impact one’s research program has on healthcare (duh!).” There is always a cover story that the research will somehow improve the quality of life. But compared to what? I am claiming that much different research — e.g., focussed on prevention — would do a much better job. The ability of people to rationalize what they do is quite good. The highest aspiration of a large number of medical school professors is to win a Nobel Prize, not to improve the quality of people’s lives. In the short term, they want a big lab and a large grant. You reach that goal by publishing many papers. They would laugh if you said their main motivation was “to improve healthcare”.

What if we’ve just chosen a trade-off between better tasting food and a shorter life expectancy? If somebody gave me the choice between 10000 hamburger-and-milkshake meals and an extra two years of life, I’m not so sure what I’d choose. Years 77-78 don’t sound like much fun, and I like hamburgers. We make that same choice every day in small ways, and it is a choice. I don’t know that doctors or drug companies are to blame, they’re essentially unarmed compared with the appeal of modern conveniences.

To which one could add as a further cause of the appalling pace of progress in American biomedical research: the top-down, centrally planned funding monopoly, with a peer review process dominated by established researchers who are deeply invested in (often) failed or unproductive theories and are not about to fund any upstarts proposing ideas that might challenge them, and with politically driven priorities that channel most of the money into whatever are the latest fads.
The growth of personal science and web-based information exchange are hopeful signs, but in America the medical gatekeepers remain a serious obstacle to personal experimentation — they keep lab testing, drugs, and devices at best expensive and at worst unavailable without a prescription. Fortunately some Asian countries (including here in the Philippines) take a less paternalistic view, and that, coupled with the incentive to promote medical tourism, may shift the center of gravity of progress to Asia.

It’s more like reporting that Dirk Nowitzki’s free throw rate has decline from 95% to 94% after improving for a decade.

I think part of the disconnect comes from ideas about economic growth. In the former we don’t need growth just to maintain the status quo. If economic growth declines by 0.1%, America is in a huge amount of trouble. If life expectancy declines by 0.1%, things are exactly the same as they were yesterday.

Great post. It’ll probably take someone you describe as an outsider with insider knowledge to really bring this issue into the public spotlight.

As for where these absurd health theories come from in the first place, I believe it stems from the contamination of politics into the research domain. When politicians make it their job to fund science and make public health guidelines, they do so 1) before the science has settled, and often reach incorrect conclusions, then 2) direct research almost exclusively in the direction of confirming rather than falsifying public health recommendations, eliminating the marketplace of competing idea. Science ceases to be science and you reach stagnation.

First, disclosure. I’m an MD who spends “vast amounts…on research” as a basic and clinical researcher.

Second, where we agree:
a. Falling life expectancy is a shame on our society.
b. Losing weight means eating less. How you get there and how much royalty you collect off books sales are details.

Now where we disagree:
Specifically regarding obesity and its consequences, the medical community has pushed decreased food intake and increased exertion to treat one of the leading consequences of obesity, Type 2 diabetes. Patients don’t do it.

If your diet is so great, the medical community will applaud you, and overweight people will build statues in your honor, just like they did with Atkins…right?

An important reason that cancer rates have increased is better detection. Please include this in your discussion.

BTW, MD’s in medical research make ~ 1/2 what they could in private practice on the whole. No one’s in this game just to be paid.

quigley, you write: “the medical community has pushed decreased food intake and increased exertion to treat one of the leading consequences of obesity, Type 2 diabetes. Patients don’t do it.”

I agree. The medical community has pushed that solution for at least 50 years. And patients don’t do it — meaning it is a bad solution. That is a sign of stagnation I don’t mention in this post: Ancient solutions that don’t work well continue to be promoted.

I’ve tried to find data that your diet works for SUSTAINED weight reduction in a study that would be applicable to a generalizable population. As you know, temporary weight loss is relatively easy. Sustained weight loss (wt loss > 2 yrs), is hard.

Quigley, in my book I show that my initial use of sugar water and extra-light olive oil (ELOO) led to a weight loss that was sustained at least 5 years. Now I do the diet using butter (nose-clipped) — a healthier calorie source than ELOO or sugar water. In 1990 I weighed 200 pounds. That’s when I started trying to lose weight. Making dietary changes that led to my theory and that the theory later explained, including the Shangri-La Diet, I have been well below 200 pounds ever since. I’m now about 170 pounds. That’s more than 20 years of sustained weight loss. I think that low-carb diets work, too, but I believe they work for the same reason the Shangri-La Diet works — by reducing the overall strength of smell-calorie associations in your diet, they reduce your setpoint. Before I discovered SLD, I lost about 6 pounds by no longer eating bread. It never came back.

Quigley, I started the Shangri-La diet on October 22, 2009 when I weighed about 222 lbs. At my lowest point since then, I weighed about 191. I’m currently hovering around 194, for a net loss of about 28 lbs. (I know it’s not quite two years.)

Here’s a quick-and-dirty graph that’s current as of July 4, 2011. The solid, darker line is a ten-day moving average.

According to the report “Life Expectancy in the United States” by the Congressional Research Service, at: http://aging.senate.gov/crs/aging1.pdf, since 1910 life expectancy has declined about 20 times-the last time before 2007-08 in 1993. Clearly it is an important event for some of the reasons mentioned but it does seem to happen, luckily, with decreasing frequency over time: 5 times in the 10s; 5 times in the 20s; twice in the 30s; twice in the 40s; once in the 50s; 3 times 60s; once in the 80s; once in the 90s and once in the 2000s. Looks like improvement to me.

Bill, thank you for bringing that document to my attention. It shows that the 1918 influenza epidemic was by far the biggest disaster in terms of life expectancy in the past 100 years. As you say, life expectancy has declined several other times.The overall trend is unquestionably a slowing down of the rate of increase. The fact that the overall rate of increase is slowing down at the same time that the number of year-to-year declines is decreasing (as you point out) suggests that improvement in data quality (less random error) is why the number of year-to-year declines is decreasing. As data quality increases, each decline becomes more significant.

Fine. You provide one anecdote, and Alex provides another. How do you know that if you’d tried something else, your weight loss wouldn’t have been better or equal? Anecdotal evidence is the weakest form of evidence of generalizable benefit for an intervention.

Quigley, the theory behind the Shangri-La Diet explains a range of hard-to-explain observations that come not only from many people but from rats. That is excellent reason to believe that if the theory is true, the phenomena it predicts will be general. You ask: “How do you know that if you’d tried something else, your weight loss wouldn’t have been better or equal?” Because I tried many other things. They produced much less weight loss.

You will see that the 2008 increase was a blip in the long-term trend of a steady decades-long decrease in mortality rates.

Here’s the real story from that figure: Today, we are avoiding over a QUARTER of the deaths that would have occured if death rates had not changed over the last 30 years. That’s freaking amazing. (Yes, that’s aggregate and hides shamefully high levels of differential mortality, but still! A QUARTER! And it’s not like people were dying like flies in 1980.)

Why look at mortality rather than life expectancy? Because life expectancy is a complicated transformation of mortality rates, and even large improvements in mortality don’t translate into large increases in life expectancy in low-mortality countries.

From http://www.deathreference.com/Ke-Ma/Life-Expectancy.html: “Since the middle of the twentieth century, gains in life expectancy have been due more to medical factors that have reduced mortality among older persons. These reductions are harder to achieve than decreases in infant mortality; hence, improvements in life expectancy at birth have slowed down.”

That’s very interesting and helpful. I agree that the steady decline in age-adjusted death rates since 1980 does not suggest stagnation. But the usual stagnation claim — “improvements in life expectancy have slowed down” — is not about early in 1980-2009 versus late in 1980-2009 but comparison of much earlier (e.g., 1930-1960) to later (e.g., 1980-2010). The statement “these reductions are harder to achieve” is not an explanation (“hence”) of the slowdown but a description of it. The big picture, as far as I can tell with this new data, is what the USC authors described: Over the last 30 years, people are living somewhat longer after they get sick, but they are getting sick at the same age. This makes sense given the overwhelming emphasis of our health care system on keeping symptoms from getting worse relative to prevention of those symptoms. For example, we treat diabetes rather than prevent it. This is a kind of stagnation all by itself: A problem becomes large (e.g., diabetes) but all you ever do is treat it. Okay, people with diabetes live a bit longer, but progress on prevention remains stagnant at roughly zero.

“For example, we treat diabetes rather than prevent it.” Seth, you remind me of people in my country complaining about high crime rates, pleading, “Somebody should DO SOMETHING!” Without being very specific at all about what “do something” might entail.

What would you have the medical community do that satisfies you that they are earnestly working on preventing, say, diabetes? Would you like to see medical practitioners applying to courts to have their patients declared legally incompetent, in order to inter them in starving houses? Hold guns to their patients’ heads and MAKE them lose weight?

Aren’t you just being a bit sore about the fact that the medical community isn’t just accepting your assertions that your diet is the silver bullet of weight control? That instead they recommend “eat less, move more” and leave it up to their patient to decide how (or if!) to achieve that, without specifically recommending your diet? Without actual hard evidence that a particular method works, it wouldn’t be appropriate for a medical practitioner to be pushing any one method. Asking them to do so under the guise of “It is both cheap and safe” is to propose a sort of dietary Pascal’s wager. From a distance your diet looks just like any other fad diet. Without significant investment in time, I cannot determine if your diet works any better than, say, eating only raw meat.

I really don’t think it’s reasonable to hold party A (the doctor) accountable for a recommendation they make (to lose weight – somehow!) that party B (the patient) doesn’t follow through with personal research and ACTION. If you’re into transactional analysis a la Berne you’ll see the problem here.

“What would you have the medical community do that satisfies you that they are earnestly working on preventing, say, diabetes?” Right now, research money is about 99% cure (study of possible cures) and 1% prevention. This is insane. It is wonderful for the people inside the research community and ordinary doctors, who benefit from that allocation. (Doctors benefit because it means more people will need to be cured — by them.) It is horrible for everyone else. When the percentages are reversed (99% of research money goes to studying how to prevent, 1% how to cure) I will know they are serious.

“Aren’t you just being a bit sore about the fact that the medical community isn’t just accepting your assertions that your diet is the silver bullet of weight control?” I don’t think my diet is the silver bullet of weight control. I do think my diet introduces an entirely new idea into our understanding of weight control and how we handle obesity. I found that something that absolutely should not work according to all prevailing wisdom — including the wisdom of the low-carbers — does work. Rather than “accept [my] assertions” the medical community should test my assertions. But with one exception (Lisa Kaufmann) they haven’t.

It isn’t just diabetes of course. The medical community’s record on prevention is terrible. Prevent heart disease by prescribing statins? Just one problem: They don’t prevent heart disease. Oops. Prevent depression? Never heard of it. Prevent arthritis? Never heard of it. Prevent cancer? Uh, doctors discourage patients from smoking — a 50-year-old idea.